Presenting a live 90-minute webinar with interactive Q&A Colossus and Other Insurance Adjustment Software: Maximizing Auto Accident Claim Settlement Offers WEDNESDAY, JULY 25, 2018 1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific Today’s faculty features: Dr. Matthew J. DeGaetano, Program Director and Founder, Personal Injury Institute , Dallas James Mathis, President, Sequoia Visions , Reno, Nevada The audio portion of the conference may be accessed via the telephone or by using your computer's speakers. Please refer to the instructions emailed to registrants for additional information. If you have any questions, please contact Customer Service at 1-800-926-7926 ext. 1 .
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Understanding Colossus 5
Understanding “Rules Of PI” 6
• Claims software program used by insurers to manage personal injury claims 7
• Reduce overhead, staffing, streamlines claims, takes human input out of equation, etc. 8
• Insurers pay ~ $10-50million per year to lease the program • But they save ~ $3 Billion per year. • Here to stay . 9
• Even at $3 Billion per year. • I get asked are they still using colossus? • Or I have been told they are NOT using colossus! 10
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• Allstate had Colossus fully implemented by 1995. • Continuum merged with Computer Sciences Corporation (CSC) owner of HCFA/CMS-1500 forms by mid-1996. 12
• Claims Processing • Proper Use of HICFA/CMS-1500 form 13
• According to Aaron DeShaw’s (highly recommended) text, Colossus: What Every Physician Needs to Know (2004), a group of the original programmers from CPL went to CSC to inform them that the program had errors/problems that needed to be fixed. • CSC rejected them. 14
Colossus determines the value of a claim based on Four general components, and roughly 12,500 data points of information from the medical records called :value drivers”. 15
What PI Cases Need From Their Doctors The Doctors Ability to Address and Identify Every Complaint and Injury… 16
Colossus determines the value of a claim based on Four general components, and roughly 12,500 data of information from the medical records called :value drivers”. 17
Colossus determines the value of a claim based on Four general components, and roughly 10,720 data of information from the medical records called :value drivers”. • (1.) The injury and related info (Dx, Tx, Px, Dur of S/S, etc) 18
Colossus determines the value of a claim based on Four general components, and roughly 12,500 data of information from the medical records called :value drivers”. • (1.) The injury and related info (Dx, Tx, Px, Dur of S/S, etc) • (2.) Permanent Impairment rating – AMA Guides 5 th 19
Colossus determines the value of a claim based on Four general components, and roughly 12,500 data of information from the medical records called :value drivers”. • (1.) The injury and related info (Dx, Tx, Px, Dur of S/S, etc) • (2.) Permanent Impairment rating – AMA Guides 5 th • (3.) Duties Under Duress – Not ADL Questionnaires 20
Colossus determines the value of a claim based on Four general components, and roughly 12,500 data of information from the medical records called :value drivers”. • (1.) The injury and related info (Dx, Tx, Px, Dur of S/S, etc) • (2.) Permanent Impairment rating – AMA Guides 5 th • (3.) Duties Under Duress – Not ADL Questionnaires • (4.) Loss of Enjoyment of Life – Not ADL Questionnaires 21
▪ Computer Software Program used by Insurance Companies ▪ The adjuster enters information about the claim into the program ▪ The program accesses over 12,500 rules or value drivers to evaluate over 750 injuries ▪ The program computes a settlement figure that is consistent with the severity of the patient’s injury 22
Insurance Industry Application of Colossus Other Processors • TEACH – State Farm • Decision Point – Progressive • Claims Outcome Advisor (COA) – GMAC & Fireman's fund • Injury IQ • Claims IQ • MYND • Injury Claims Evaluation (ICE) • XM • And one of the newest Lemonade, INC. 23
Insurance Industry Application of Colossus Other Processors • TEACH – State Farm • Decision Point – Progressive • Claims Outcome Advisor (COA) – GMAC & Fireman's fund • Injury IQ • Claims IQ • MYND • Injury Claims Evaluation (ICE) • And one of the newest XM 24
Insurance Industry Application of Colossus Other Processors • TEACH – State Farm • Decision Point – Progressive • Claims Outcome Advisor (COA) – GMAC & Fireman's fund • Injury IQ • Claims IQ • MYND • Injury Claims Evaluation (ICE) • And one of the newest XM 25
When pain and suffering is determined? 26
When pain and suffering is determined? The real question by colossus… 27
Is there a permanent impairment? 28
Colossus
Colossus
Soft Tissue Injuries are under Attack by the Insurance Companies 31
Connective Tissue Injuries Are Anchored By the AMA 32
What is the degree of the pain and suffering? 33
What is the degree of the disability? 34
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INSURANCE CLAIM PRACTICES AND PROCEDURES AND THEIR SOFTWARE THAT DENIES CLAIMS 37
What do you need to consider: • Currently there are: – 86 different software programs in use • Medical determination software • Claim evaluation software – One significant manual evaluation – 10,720 value drivers – 17,000 severity drivers – 1,600 claim practice procedure programs – One major data management company 38
Colossus, , XM, TEACH, MYND, Decision Point, Injury Outcome, Injury IQ, COA, ICE FairHealth, IMS, AIM, MEDICO, MBRS, ADP, Ingenix, HELP Systems, InjuryIQ, AIM, Mitchell Medical, Med-Data And now IBM’s Watson 39
The Beginning of a new ERA • Mitchell/Decision Point relies upon a database maintained and manipulated by Ingenix . • Ingenix is found to be fraudulently corrupt by New York Attorney General. • The AMA filed a civil suit on behalf of New York vendors against Ingenix and it settled for $380 million. • Use of Ingenix allows that the insurer to only accept as reasonable a “ Percentile ” range of charge for medical treatment and testing. 40
The Beginning of a new ERA • CSC, owner of Colossus, is now managing all data and evaluation of medical billings for Blue Cross Blue Shield and Group Health. • MBRS, ADP, AIM and Med-Data are being fazed out in favor of universal use of FairHealth and Mitchell Medical Expert softwares. 41
Resulting Outcome • No ownership of claim • Early Objective testing • Claim maximizes within 120 days • Deny medical necessity of treatment • Deny Minor Impact • Reject Injuries • Refuse future treatment costs • No responsibility for value • Take it or leave it attitude • Solicit litigation against their own insured 42
New Valuation Focus • Injuries (Number & Type) • Treatment Modalities & Cost • Symptoms • Physician Type • Future Treatment • Body part at static MMI • Impairment • Duties Under Duress • Loss of Enjoyment • Final Prognosis 43
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